Flaura Koplin Winston, M.D., Ph.D., is Founder and Co-
Scientific Director,
Center for Injury Research and Prevention, The Children’s Hospital of
Philadelphia, Philadelphia, and Senior Fellow, Leonard Davis
Institute of Health Economics at the University of Pennsylvania.

An Interview with Flaura Koplin Winston
Raising a Mensch Editor, and Recipient of the John M. Eisenberg Patient Safety and Quality Award.

-- David A. Asch, M.D., M.B.A.

Dr. Winston's primary research focus is traffic injury. She
is the Principal Investigator for research funded by the
National Highway Traffic Safety Administration, the
National Science Foundation, the Maternal and Child
Health Bureau, and State Farm Insurance Companies.
Some of her most notable research findings include the
identification of the first cases of child fatalities from air
bags and the delineation of the mechanisms of injury, the
importance and prevalence of suboptimal restraint of children
in motor vehicles, the incidence of and risk factors
for posttraumatic stress disorder in children and parents
after child traffic injuries, and the teen perspective on
driving risks and their prevalence.

Your background as an engineer and a pediatrician
with a background in public health seems ideal for the job
you have in traffic injury prevention. In fact, I have heard
you referred to as "the link." What has your cross-disciplinary
training taught you?

Important problems in our society require more than a
multipronged approach; they demand interdisciplinary
work. Without such integration, approaches to finding
and implementing solutions can be fragmented and inefficient.
Injury epidemiologists recognize the wide range of
variability in humans and can provide accurate estimates
of the magnitude of a hazard. They answer who, what,
where, and when children are typically injured in this way.
Injury engineers apply laws and principles of physics and
other basic sciences to systematically analyze injuries to
children as vehicle and restraint design failures. They
answer how the injury occurred to recommend prevention
strategies. Injury behavioral scientists view the injury from
the human and social contexts and answer why it happened,
recognizing that we can never engineer out behavior.
Epidemiologists, engineers, and behavioral scientists
are necessary to create a full picture of the often fragmented
injury puzzle and provide insights into solutions.
However, without cross-disciplinary exchange, the picture
will remain a pile of disconnected pieces.

Over the past decade, I have worked to ensure that our
injury research and prevention team at The Children's
Hospital of Philadelphia and the University of
Pennsylvania is truly integrated and interdisciplinary. I
believe that this is why our work has had both breadth and
depth. My engineering colleagues know the limits of engineering
and when epidemiology, behavioral science, or
another approach is needed to solve a problem and vice
versa. When this scientific handoff is required, a nearseamless
transition occurs. Bringing their different viewpoints,
multiple experts come together to interpret one
another’s work. This rich environment is found in the
most productive medical laboratories and has been recognized
as an integral part of the National Institutes of
Health (NIH) Road Map. I suggest that future medical,
health services research, and public health training include
at least an introduction to the principles of behavioral science
and engineering to facilitate our efforts to find
answers to the complex problems that we face in medicine.
In addition to conducting clinical research and engineering
studies, I remain a practicing clinician. This regular
contact with patients keeps me grounded in reality and the
ongoing high prevalence of injury and its prevention. As a
result, I work to advance my science from "the bench to
the bedside" to provide optimal care.

I suspect that when many people think of patient safety,
they only consider those who are sick in hospitals or clinics.
Your work focuses at least as much on what happens in the
community—before people become "patients" in the first
place. Is our current thinking about patient safety too constrained?

Hospital-based patient safety is necessary but insufficient
if we truly want to make a difference in our nation’s
health. Physician error reduction plays an important role
in tertiary prevention: decreasing morbidity and mortality
once a patient has a disease or injury. We will have much
more impact, however, if the patient never contracts the
disease or suffers an injury.

To achieve this goal, we need to focus on community and
ambulatory-based prevention strategies that are primary
(reducing risk and exposure) and secondary (reducing
incidence and severity). Quality improvement
programs should be expanded to identify and address "prevention
errors," such as the health system’s inability to
effect changes that reduce crashes and increase use of
appropriate restraints in motor vehicles. This is not a new
concept for disease prevention: think "vaccine failure."
When a child today contracts a vaccine-preventable disease,
physicians are required to notify the health authorities,
and steps are taken to avoid a recurrence in another
child. For example, a recent response to post-vaccination
varicella occurrence was a requirement for a booster dose
of vaccine.

Once we have an understanding of the necessary prevention
strategies, we need to deliver them through effective
programs and to sufficiently fund the initiatives. It is
also imperative to develop best practice guidelines for prevention
and counseling and to measure the effectiveness of
our programs. For this to occur, we must develop sound
prevention quality performance and effectiveness metrics.
Policymakers might consider requiring their measurement
by health care entities, possibly as part of accreditation by
The Joint Commission, and, if so, health care funding
should reimburse for this time well spent. "Do no harm"
is an important goal for protecting our patients, but it is
not enough.

You helped "medicalize" child passenger safety. But you
also brought in nonmedical stakeholders to join you. Why
was this important, and how can these partnerships be
expanded to other areas of health care and other areas of
health?

As an academic physician, I recognize that my work
will have little impact on the public’s health if my end goal
is publication in high-impact journals. For each of my
research findings I know that there are many nonmedical
audiences needing to be reached. These include legislators,
policymakers, employers, engineers, designers, and families,
all of whom have a stake in translating injury prevention
research into action. Unfortunately, our academic
publications are not easily accessible by them.

In my approach, I incorporate these stakeholders, the
end users of my research, into the research plan. Before I
embark on a study, I review the research question and proposed
data collection with representatives of the stakeholder
groups to determine if my planned data set is
complete. Would the relevance of the research be
enhanced by additional questions with associated data
elements? Once my team conducts the study and analyzes
the data, I return to these groups of "policy influencers"
to help interpret the results and to suggest plans of action.
Finally, I translate the science into terms that matter
and create materials and training on their use for these various
groups, the "stakeholders for the science." This
integrated "research-to-action" approach fosters efficient
knowledge transfer, due in part to the tremendous buy-in
from the beginning of the research by the people who
have the power to implement change based on the
findings.

The National Science Foundation awarded our Center
an Industry/University Cooperative Research Center designation, which is another example of how this knowledge
translation works. This little-known program was established
several decades ago to promote efficient corporate/
academic exchange and to leverage resources for fundamental
research. This model of cooperation was adopted
recently by the National Cancer Institute investigation of
orphan cancers. I believe that such industry/academic
partnerships, with safeguards in place for academic freedom
and scientific integrity, are essential to advancing
health.

Whose job is child passenger safety? If the buck stops
here, where is here?

There are many people who have much to gain by universal
child passenger safety. If I had to say where the buck
stops, however, it is with the parent or caregiver who is
transporting the child. Unfortunately, the answer is not
that simple. Many parents lack the necessary knowledge
about or access to appropriate automotive child restraints.
As a result, the safety of our children in motor vehicles is
in jeopardy. The issue is paramount. Consider these statistics:

In 2000, injuries to children ages 10 and under
resulted in an estimated $5.7 billion in direct medical
expenditures.

For every child injured, the total cost is more than
$12,700, including $650 in medical costs, more than
$1,000 in future earnings lost, and nearly $11,000 in lost
quality of life.

Every dollar spent on a child safety seat saves this
country $32 in direct medical costs and other costs to
society.

These statistics translate the human costs of injury into
financial costs. Not only are child restraint systems effective
in reducing injuries and deaths; they’re also cost-effective.
In a recent analysis, we demonstrated that child safety
seat and booster seat disbursement and education are just
as cost-effective as several of the vaccines delivered as part
of the Vaccine for Children program. It is time for the
health care community to recognize the medical benefits
of safety devices.

You break down car crashes into what happens before
the crash, during the crash, and after the crash. Clearly, all
of these time frames are important, but does intervention
in any of these offer more promise for success than others?

Have you ever heard the old saying, "An ounce of prevention
is worth a pound of cure"? Preventing the crash is
the obvious best approach. One specific way to prevent
crashes is to develop strategies to improve teen driving,
particularly during the first six months, and to reduce
drinking and driving in all age groups.When we fail to
prevent the crash, we need to be sure that backup prevention
strategies are in place. Optimal restraint for every trip
is a proven effective strategy. We reduce by half the risk of
injury in a crash by restraint use; for our children, we
achieve another 2/3 reduction in risk by placing them in
age-appropriate restraints and seating them in the rear seat
until at least age 13.

As a final backup strategy, we rely on the most expensive
and most intensive resources, including trauma resuscitation,
acute care, and rehabilitation. Survival after
injury greatly depends on the strength of the victim’s local
trauma system. The system must include rapid emergency
medical response teams qualified in adult and pediatric
trauma care and qualified trauma medical facilities. To
guarantee high quality, rapid trauma care delivery for all
Americans, regardless of geography, continued investment
and expansion is required.

But to ensure optimal outcomes, trauma care has to
look beyond the physical injury realm to address the
prevalent psychosocial consequences of the injury and to
minimize the trauma of medical care. Even in the absence
of injury, the trauma of a crash can have detrimental psychological
effects.

Recently, the Substance Abuse and Mental Health
Services Administration coined the term "traumainformed
care." Such ideal clinical care for injury and violence
would address not only the survivor’s medical and
surgical needs, but also the survivors’ response to the trauma.
This care would thereby aid the healing and rehabilitation
process. Moreover, from a staff perspective, a
trauma-informed approach would result in a cultural shift
that recognizes and addresses the personal, emotional
stress associated with caring for these patients. With this
approach, the work environment would become more
effective, patient outcomes would improve, and, ultimately,
bottom-line costs would be reduced.

Some people probably don’t see child restraints as sufficiently medical, but you’ve demonstrated how profoundly
you can affect health with them. Why can’t medical
providers prescribe child safety seats?

Child safety seats, booster seats, helmets, and other
safety devices are proven to prevent injury. Despite this
knowledge, many children in our country ride in vehicles
without appropriate restraints, creating a health disparity
in injury. In particular, minority and non-English-speaking
parents lack the resources to purchase child safety seats
and belt-positioning booster seats or lack the knowledge to
use them correctly. Therefore, their children ride unprotected
and are at disproportionate risk of injury.
Pediatricians highlight the importance of appropriate
child restraints in motor vehicles as part of anticipatory
guidance despite the fact that they do not receive reimbursement
for this counseling. However, they are precluded
from eliminating the access barrier because child
restraint systems are not allowable as a direct medical
expense.

Similarly, effective and promising interventions are
under development to prevent crashes among novice teen
drivers, the population with the highest fatal crash risk.
Restrictions on prevention services by some insurance
plans will limit physician referral for these remedial and
prevention strategies. As a result, effective prevention
interventions will have limited avenues for dissemination
despite the fact that some states require pre-driving physical
evaluations by physicians. Physicians are forced to
make determinations of risk without being able to offer
the antidote. If our health system continues to limit prevention
activities by physicians, our current level of annual
crash fatalities, if left unabated, predicts that more than
100,000 children, youths, and young adults will die in
crashes in the next 10 years.

As a society we can no longer sustain a health care system
that relies on treatment for disease and injury as our
primary clinical strategy. We need to begin to allow medical
expenses for prevention, particularly safety devices and
interventions. We also must now invest in research to
determine cost-effective, best practice models for the dissemination
of prevention strategies and metrics to measure
compliance and effectiveness. This is imperative not only
through the health care system, but also through other
touch points for guidance and resource distribution, such
as schools and day care centers.

What are the pressing needs for the advancement of
injury prevention and trauma care?

I believe that injury research, training, and translation
are the areas of greatest need to address the "epidemic" of
injury, but current allocation for these areas of focus are
only pennies on the dollar of funds allocated to disease. As
a result, it is difficult to attract the most promising scientists
and clinicians to the field. With limited funding available
they see a difficult future: Scientists have no guarantee
that important, resource-intensive studies and trials will be
conducted to advance their area of study, while clinicians
fear that they will not be reimbursed for their services.

It is the domino effect. Since there’s insufficient funding
and little emphasis placed on them by the medical
community, many proven effective prevention strategies
are not implemented. As a result, preventable injuries likely
occur every minute in this country. Several will likely
happen while you’re reading this interview. Finally, trauma
care needs to go beyond the treatment of the physical
injury. It has to move to treating the likely psychosocial
consequences, focusing not only on full recovery, but also
on prevention of recurrence. PTSD (post-traumatic stress
disorder) is a common outcome of injury; yet, most
injured patients with PTSD go undiagnosed and untreated.
As another example, alcoholics with injuries all too
often get patched up and sent out without adequate treatment
to address the root cause of their injury, their addiction.
Victims of domestic or interpersonal violence also are
often treated and released to the same setting where the
incidents occurred without any guidance or resources to
prevent future injuries.

It is important to remember that injury and violence
are the leading causes of death for all ages from 1 to 44 and
the leading causes of acquired disability and lost years of
productive life in this country. It is our responsibility as a
health care delivery system to prevent or reduce the chance
of injury when crashes and other potentially injurious
events occur, treating the injuries for which our prevention
efforts failed, and discharging our patients to a safe environment
with the proper care to connect them with the
interventions that will reduce their risk of recurrence. We
need to optimize our health care delivery system with primary,
secondary, and tertiary prevention strategies. We
also must invest in the necessary training, research, and
resources to advance and deliver this care. J